Wrong drug, no negligence

I enjoyed reading your article “Wrong drug, no negligence” in the May 2014 edition of Casebook. As a trainee anaesthetist I can remember making exactly the same mistake during my first month of training, ie, administering a full dose of coamoxiclav to a patient with penicillin allergy whilst under anaesthesia. Fortunately the patient suffered no ill-effects whatsoever, and postoperatively she admitted she was sceptical about whether she had a true allergy or not, and was glad that we had inadvertently found out.

Drug administration errors in anaesthesia are common, with some studies suggesting one error in every 133 anaesthetics.1 In your article you state the anaesthetist may have been distracted by the use of the total intravenous anaesthesia technique. This is probably not the only factor, as observational studies have shown that on average an anaesthetist is distracted once every four to five minutes during a routine list.2

Thus the propensity for making errors is huge and it would seem only a matter of time before an error leads to a catastrophe that makes headline news. On wards and on intensive care units, nurses have long ago moved to using a two-person check system prior to the administration of harmful medication. Since anaesthetists have access to some of the most dangerous medications in the whole hospital, how vulnerable are we to litigation claims, given that we still use a single-person check? Should we be pushing to implement a two-person check as well, to protect both us and our patients?

Drug administration errors in anaesthesia are common, with some studies suggesting one error in every 133 anaesthetics

Thank you for your observations on this case. The expert in this case did carefully consider the issue of causation, and in particular the question of the infection that developed in the knee. His opinion was that the infection would not have developed if the patient had not required early revision surgery due to the substandard index operation. He was also of the opinion that had the initial procedure been carried out appropriately, the prosthesis would not have needed revision until it failed – in approximately 15 to 20 years. The settlement in this case reflected these issues.

Manslaughter

I enjoy Casebook, which reminds us that there are always new errors, and that old errors are easily repeated.

In "Medicine and manslaughter” (Casebook UK only) you kindly refer to the review that Sarah McDowell and I wrote of medical manslaughter between 1795 and 2005. But you then state that “other widely-reported cases include” and cite Mulhem (2003) and Walker (2004). This might unintentionally suggest that we omitted these from our review. They are, respectively, cases 7 and 14.

Incidentally, the trend towards long prison sentences for surgeons started with R v Garg, which seems to have attracted little attention; and the verdict in the Sellu case was reached in spite of the fact that the judge was reported to have said that the patient might have died even if he had received the proper treatment promptly.

Photo criticism

I just wanted to let you know that I find Casebook really helpful, well-presented and useful (if a little frightening at times!). I also wanted to make a small criticism about some of the photos that let down the otherwise professional approach.

I am a bit behind on reading them but a case in point was the Jan 2014 edition (volume 22), "Common can be complicated", which showed an otoscope being held completely wrongly, in the wrong hand and without an earpiece. I suspect any lay person would not notice but it would be worthwhile getting a doctor to check the photos before publication to avoid similar errors, which look terrible to doctors.

I hope you understand that I am making the point to improve the journal rather than be overly critical.

Dr Samantha Dunnet
GP, UK

Response

Thank you for your letter about the photograph in the January 2014 edition of Casebook. The pictures used in Casebook are not accurate representations of clinical situations, but rather to illustrate the general theme of the case report or article. We do have a notice to this effect at the foot of the Casebook contents page, although the font is rather small and might benefit from being a little more prominent.

The content of each issue of Casebook is reviewed in its final form in our layout board meetings, and these always include a number of doctors from a variety of clinical backgrounds. Whilst no comment was passed about the use of the picture in question, your comments will be a timely reminder for the board members.

The accused

The story left me feeling quite angry at the fact that the patient in the matter was able to simply shrug off an apparent malicious claim against the GP without any consequence. I can completely understand the professional reluctance to do so, but would there be an argument in this case to pursue a civil claim of libel, given the significant impact this claim has had on the doctor both professionally, emotionally and undoubtedly financially?

Dr T Broughton
Consultant Forensic Psychiatrist, Norfolk, UK

Response

Whilst it might seem an attractive proposition to contemplate some form of legal redress in these circumstances, there are a number of significant practical issues to consider.

Firstly, MPS experience is that nearly all complaints of this type are made by genuine complainants who have misunderstood or misinterpreted a clinically appropriate examination carried out in a reasonable and responsible manner.

The second point to consider is that as a matter of public policy, most legal systems provide some form of protection against allegations of defamation for complainants who take their concerns through appropriate channels. This is because otherwise there would be a very chilling effect on the ability of members of the public to raise concerns, particularly where a defendant may be able to access much greater resources than the complainant.

As a matter of public policy, most legal systems provide some form of protection against allegations of defamation for complainants who take their concerns through appropriate channels

Additionally, in criminal cases, the decision to prosecute rests with the prosecuting authority rather than the complainant. In England and Wales, for example, this rests with the Crown Prosecution Service, who will weigh up the issues before deciding to proceed with a case. This includes assessing whether there is sufficient evidence, whether the evidence is reliable and credible, and whether a prosecution is in the public interest.

Finally, even if there were no other hurdles, and it was possible to consider an action in an individual case, it would be an unattractive case, which would be liable to attract adverse publicity, and in the event of success, given the financial position of most complainants, a doctor (or their MDO had they agreed to undertake the matter) would be unlikely to recover their costs, let alone any damages actually awarded.

Realistically speaking therefore, it is unlikely that we will see cases of this sort being brought.

The accused

The excellent article “The Accused” (Casebook 22(2), May 2014) leaves an obvious question, which would be valuable to consider…

What is MPS’s advice for the doctor when the patient declines the chaperone? Is the doctor at risk if they refuse to proceed with an examination without a chaperone? What should they do, in that event?

Other readers may also wish to know your response – it seems important.

Dr Mark Davis
New Zealand

Response

Thank you for your letter, which raises a very important issue.

Generally speaking, if a chaperone is declined by the patient, and you don’t want to go ahead without one, you should clearly explain why you would like one to be present. You could also consider referring the patient to a colleague who would be willing to examine without a chaperone. However, the patient’s clinical needs must come first, and any such arrangements should not result in delays that affect the patient’s health.

The patient’s clinical needs must come first, and any arrangements should not result in delays that affect the patient’s health

The discussion about chaperones, together with the outcome, should be recorded in the medical record. If a chaperone is present, record that fact, and their identity. If the patient refuses a chaperone, make a note that the offer was made and declined.

There are often local guidelines or protocols that cover this issue, and members should make sure they are aware of these and follow them.

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